How to meet the primary care demand in the next decade

by Travis G. Bias, DO

Throughout my involvement in organized medicine, I’ve met friends who I hold in high regard, and colleagues for whom I hope to one day work.  One of my favorites, a neurosurgery resident buddy of mine, claims specialists should be paid more than primary care physicians.  But, I am a third-year family medicine resident, preparing to enter the practicing world.  And thus, it is with great respect that I offer this counterargument.

The primary care physician is the quarterback.  In more ways than one.  The primary care physician shoulders the responsibility of making numerous initial diagnoses, treating and managing all cardiac risk factors, and ensuring patients are directed towards the right levels of care.  We are also the center of chronic disease management, the source of 75% of health expenditures in the U.S.  Primary care visits save money by preventing poor outcomes and maintaining health.

For this very reason, we need more primary care physicians in the face of a 45,000 physician shortfall anticipated nationwide by 2020.

How do we meet this demand?  It’s very simple.  Pay primary care physicians more.

The first argument against this is that specialists undergo longer, more extensive training.  I absolutely agree that a physician whose residency is longer should be paid more.  Hands down.  My friend the neurosurgery resident will train for 7+ years after medical school, compared to my three.  He trains an additional four years that he can’t be making significant strides towards paying off his educational debt.  He is the king of delayed gratification, more so than the rest of us.

But how much more should he make?

Currently, he will make at least four times as much.

His training also may be more difficult at times, but all residents undergo the same stressors.  We experience stress on our relationships, both romantic and with our family.  We undergo sleep deprivation.  We miss friends’ weddings.  The life stress is comparable.

The next argument is that subspecialists are subject to greater risk.  Currently, physicians are reimbursed for procedures.  Procedures inherently carry with them a great malpractice burden – if the surgeon’s technical skills aren’t up to speed, or his/her judgment is flawed, life-threatening mistakes can be made.  But how does this compare to the missed or delayed diagnosis, the cause of many primary care lawsuits?  Or how does this compare to not adequately covering every single medical problem for the patient with an extensive medical history?  Even when a patient is referred to a specialist, they are generally referred back for the primary care doc to manage the treatment or monitor its effect.

Not only does a primary care practice not generate revenue from a high number of procedures, but we are not paid a dime for the skills we are trained to do best – think, communicate with patients, communicate difficult diagnoses, communicate with difficult patients, e-mail patients, call patients – you get the point.  None of the aforementioned skills are reimbursed by insurance companies, and the only one you might make an argument for is “thinking,” yet this is at a far inferior rate than that of a procedure.  I get paid much more for taking off a mole than just talking to my patient.

When in medical school, most of us just see the family physician as the one dealing with coughs and colds, and the one referring out to specialists for the real treatment.  But only deep into family medicine residency and practice does the family doc appreciate the depth of care delivered in the primary care setting.  We manage COPD, diabetes and other cardiac risk factors.  We deliver babies, give flu shots, do pap smears, and help our patients to quit smoking.  We remove suspicious moles, evaluate knee pain, and manage anxiety.

And most importantly we take the time to listen to our patients to get to the root of the problem.  Treating abdominal pain with expensive CT scans, antibiotics, and hospitalizations does no good if the patient is simply depressed.  Simply knowing your patients can save money and maintain a high level of quality.  My parents’ family doc of over 30 years knew them, and thus instead of the hospitalist admitting my father to the hospital one Thanksgiving Day, we simply called his family physician on his cell phone and, the following week, commenced the appropriate work-up in the appropriate setting – outpatient, and not in the hospital over the weekend.

Properly reimbursing primary care physicians for their coordination, communication, and quarterbacking skills will in turn incentivize medical students to enter the field of primary care.  This is how we will appropriately meet the primary care demand and shortage in the next decade.  It’s that easy.

Travis G. Bias is a family physician who blogs at Life’s Residency.

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  • HJ

    Another post on the discrepancy between primary and specialist pay?

    The work that specialists do has more value. Removing that brain tumor is worth more than a conversations about cholesterol.

    • http://thedocsquawk.com thesdocsquawk

      Neurosurgery has more value than primary care? Which do you think would have a bigger impact? No neurosurgeons or no family doctors?

      • HJ

        “Which do you think would have a bigger impact? ”

        There are a few medical professionals that have a great impact on my life. None of them have been family doctors. Number one is a physical therapist.

        “No neurosurgeons or no family doctors?”

        Most of my experiences with primary care the involve NP/PA. I suppose if there were no family doctors, my care over the last 10 years would have been about the same.

    • http://bensnotes.wordpress.com/ Ben M2

      I agree. Specialists should probably be paid more than primary care physicians, just because the procedures they do are generally more risky and involved than anything a primary care physician does. Also, we need to motivate students to undergo the 7 year residency and long, long hours of working as a neurosurgeon.

      However, primary care physicians definitely need to make more so that we can motivate more students to enter primary care.

      As for specialists having more value… I don’t think so. Specialists and primary care docs have different value. Someone has to diagnose the brain tumor before the neurosurgeon can take it out. And if you’re not motivating some of the best and the brightest to spot these life-threatening diseases from a myriad of every day conditions, then you might start to get into some trouble.

      • Dr Im-Getting-Out-of-Here-While-I-Can

        BEN!

        How r u? I’m Dr IGOWIC (Dr Im-Getting-Out-of-Here-While-I-Can). Remember me? So any new thoughts from you on what specialty you are going into? Just curious.

        Hope all is well.
        Dr. IGOWIC

        • http://bensnotes.wordpress.com/ Ben M2

          Haha, hi Dr. Igowic. Yes! I have decided. I’m an NHSC scholar now, so I’m locked into primary care of some kind. I’m super-excited about it, but I haven’t quite decided what kind of primary care I’m going into (Med/Peds, Family, IM).

          • Dr Im-Getting-Out-of-Here-While-I-Can

            Ben,

            Oh Ben, precious Ben, what have you gotten yourself into! Tell me it ISNT SO! After all out talks?!?

            Well, what’s done, is done.

            Primary Care can be a very rewarding field (I should know, I do it), emotionally so that will be the hallmark of your future.

            May I make a suggestion? Do IM. Or Med/Peds. That way when you realize how BAD BAD BAD the pay is, you can subspecialize in an IM field. Hear me now, believe me later.

            But why Fam Med? Are you really interested in OB? A majority, maybe a vast majority of FM don’t do OB, so it’s wasted training for most of us.

            But gosh, I wish you the best. Try to enjoy this challenging but exciting time of your life.

            Dr IGOWIC

  • family practitioner

    Comparing us to neurosurgeons is apples to oranges.
    A better comparision would be with radiology, or anesthesiology, or dermatology,

    Forget college, we all go to college. Med school is four years, a peds, fp or im residency is 3 years, for a total of seven.

    Most anesthesia, radiology, derm residencies are 4 years, for a total of 8 years. This is about 15% longer; therefore, if your only criteria is years of study, those fields should earn 15% more than primary care doctors. In reality, they earn 200-300 % more so obviously other factors are at work.

    A GI fellowship is 2 years, for a total of nine years, which is 30% more; however, GI doctors also make 200-300% more than primary care.

    The risk argument is difficult, because it is subjective. We all have risk. If risk ruled the day, then general surgeons and ob-gyns would make more than anesthesiologists but alas this is not the case.

    The bottom line truth is that some fields of medicine are overpaid, and others are underpaid.

  • MDL

    more value? HJ…thats a pretty bold statement. Obviously neurosurgeons should be payed more for the “technical/surgical skills”
    Although one could argue robots due much of the heavy lifting these days.

    Preventing that heart attack (your cholesterol comment) I believe has a lot of value, and no not just by talking to the patient but usually one advises pharmocotherapy and lifestyle modification.

    • HJ

      “I believe has a lot of value, and no not just by talking to the patient but usually one advises pharmocotherapy and lifestyle modification.”

      If I wanted to reduce my chances of having a heart attack and felt my lifestyle was a culprit, I would look it up on the internet. As for pharmocotherapy, there is a 99% chance that if you prescribe Lipitor, there is no value-even if I have risk factors.

      It’s clear that surgery to remove a tumor is valuable. It’s also clear with a Framington 10 year risk score of less than 1%, discussing cardiac risk factors is not valuable.

  • guest

    How about specialists are underpaid and primary care is even MORE underpaid? No reason to get into a big argument about one’s relative value. All this would be a moot point in a market-driven health care environment…

    • Justin

      I agree that physicians are underpaid, and that arguing against each other is not going to get us anywhere. I think an interesting way for physicians to get paid (for all the work we do) would be to allow physicians tax breaks for giving charity/unreimbursed care; possibly tie this into repaying student loans with pre tax dollars to functionally increase physician income.

  • http://www.BocaConciergeDoc.com Steven Reznick MD FACP

    As a primary care physician I never advocated paying us more than the surgical specialites or many medical specialties that require extra training and a major capital investment in equipment to set up their practice. All i ask is that I be compensated fairly for spending time with my patients,being their advocate, coordinationg their care and trying to keep them healthy , I ask that if I give my patients the time they need to listen to their complaints I will be able to meet payroll, pay the rent and make a fair living so I can support my family.

  • Dr Ash

    As a PCP whose best friends are all specialits, well said Dr. Reznick, Well said.

  • stargirl65

    The specialists I know all socialize in different circles than I do. Their income in 3-5 times my income. They go on long international vacations, get a new, expensive car every few years, go to theatre and nice restaurants.

    I go camping for vacation or to my inlaws. I drive a 1999 minivan. Our big nights include a fire pit in the back yard and watching netflix movies.

    We walk in different circles.

    I do think that treating someone’s hypertension or cholesterol is very important. It is not as glamorous as placing a stent but it may prevent the necessity for the stent ever being placed.

    Many people come to me with vague problems that need diagnosis. Often I can solve the problem, but if a specialist is needed I am in a better position to know where to refer the patient than the patient.

    • HJ

      “I do think that treating someone’s hypertension or cholesterol is very important.”

      I think it is more valuable to prevent hypertension or high cholesterol. Perhaps a personal trainer should be paid more.

  • Larry Sinatra

    There is a large supply of primary care physicians available in the US that will lessen if not relieve the “primary care doc shortage”. That reservoir is known as the Department of Veterans Affairs (the VA). The VA has hired thousands of primary care physicians in the past 10 years that are truly unnecessary. They do not practice medicine. Many of them fill administrative jobs that can and should be done by administrators, many of them do meaningless physicals which are little more than data gathering for what are essentially government sponsored research projects, and many, many more simply rewrite prescriptions for community physicians on whom the veterans actually rely for their primary care. Why is this? The rules say that to access the VA pharmacy (which is essentially free by comparison to the real world) the prescription must be written by a VA physician. If these rules were changed the VA would have no need for all these primary care physicians and they could go out into the community and practice real medicine.

  • http://www.davisliumd.blogspot.com Davis Liu, MD

    Yes more money would be helpful, however, it is naive to think it is that easy to inspire the next generation of doctors. Most are looking for work-life balance, which the current form of primary care doesn’t address.

    Until insurers compensate for cognitive medicine (rather than fee for service) and primary care doctors are wired with robust electronic medical records (decrease hassle factor / uncertainty of finding and acting on information – vital for a cognitive specialty), primary care medicine will continue to be the increasingly speedy treadmill doctors want to step off of or never get on.

    Otherwise avoiding the discussion of the federal government’s role of community clinics, the future of primary care will thrive in large integrated healthcare systems like Kaiser Permanente (as it current does today) and the solo practitioner doing the ideal medical practice.

  • gzuckier

    If specialists deserve to be paid more because of the longer and more difficult training process, then biology/biochemistry/biophysics PhDs should be paid more than specialists.

  • http://www.theblackribbonproject.org Beth Haynes, MD

    Value is in the eye of the beholder—or perhaps better yet (at least for economic transactions) the wallet of the payer.

    The problem is not who should get paid more, but who is making the decision on how much to pay. Right now health care suffers from a myriad of government price controls and price supports, all of which distort the proper functioning of market signals.
    Who should get paid more? Nobody knows since supply and demand are not currently setting the price. If we allowed the market to work in health care. profits would shrink in areas of over-supply and increase in areas of real shortage. Instead, people keep trying to figure it all out via top-down central planning. Doesn’t work. Never has. Never will–because, value is in the eye of the beholder–at least in a free country it is.

  • IMG

    “Necessity is the mother of invention”. As a future primary care physician I would like to make workload easy for the PCP’s and at the same time increase and broaden the knowledge base of primary care residents. To decrease workload there are already EMR’s and other technological advances that help the PCP deal with the daily stresses and its going to only get better in the future. If PCP’s try to master all the minor surgical skills during their residency or with special certifications and manage all the complex but common cases of specialists (Endo,Derm,Cardio,Rheum,Psych and peds)they can take a chunk out of the specialists cases. If the PCP is not able to run his practice and make ends meet then the PCP has to step up and grab all they can. Diversify and rule is the only option left.

  • http://www.premiere-health.com FamilyDocinNC

    Throw away the government/insurance pay model for primary care. Health Insurance IS NOT healthcare. It is only one means of paying for it. Health insurance IS NOT true insurance, like your auto or home policy is … but IT SHOULD BE. Why? Because primary care is “maintenance”, low cost, and should not be “covered”. This solves 2 problems. (1) Health insurance premiums would drop, making health insurance more affordable. (2) By not being “covered”, health insurance “rules” do not apply and primary care physicians could be fairly compensated based upon their quality and price of services rendered.

    Barring these two developments … there is no other choice but to quit Medicare, Medicaid, and ALL other insurance plans. Many small, privately owned primary care practive physicians HAVE to work 2nd or 3rd jobs to support their families, because the government’s and insurance industry payments do not sufficiently cover the significant overhead of running a primary care medical practice.

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